youth sports safety

Over the past three years, 17 high school football players have died after sustaining head injuries while playing. A similar situation in the NFL would have caused a national uproar, so how has this been allowed to happen to our youth?

Take a look at trailer for this riveting episode of HBO’s series Real Sports with Bryant Gumbel, which is airing several times on HBO through mid-December 2016, as well as On Demand. The episode as a whole explores why there are such inconsistencies in protecting professional athletes versus the youngest players.

A number of research articles suggest that women are more susceptible to mild Traumatic Brain Injury. In fact, female college athletes have a higher rate of concussion compared to males when playing soccer (2.1 x greater risk), softball versus baseball (up to 3.2 x greater risk), and basketball (up to 1.7 x greater risk). So, why the difference? Research and anecdotal evidence has turned up three possible reasons: cultural differences; hormonal differences, or physiological differences.

Canada forward Christine Sinclair (right) and USA midfielder Carli Lloyd head the ball during the 2016 CONCACAF women’s Olympic soccer tournament at BBVA Compass Stadium in Huston, Texas, on February 21. Soccer is also among those sports programs that produce a large share of concussions for female athletes. — Reuters

Some experts have said part of the reason for increased concussions in females may be due to the reporting rate — that women are more likely than men to notify a coach they are injured, whether due to a head injury or other concern. Cultural differences indeed indicate a reluctance among males to report any injuries for fear of being removed from play. However, because of the very nature of concussion being a clinical diagnosis that usually depends on self reporting, it is hard to say that the incidence differences between the genders is due to honesty.

Other research suggests that hormones including estrogen, oxytocin, progesterone, and testosterone, affect recovery times from concussion. Of course, men and women have vastly differing levels of these hormones. One published study from the University of Rochester (NY) has also shown that menstrual cycles play a part in healing from head trauma. The research showed that women in child-bearing years experience greater cognitive decline, delayed reaction times, extended periods of depression, more headaches, and longer hospital stays and return-to-work plans compared to men following head injury.

Other research suggest that there are different neuronal connections between the hemispheres and significant lobes within the cerebral cortex for men and women potentially influencing recovery time. A recent Georgetown University Medical Center study showed that mice with a single head injury temporarily lose 10 to 15 percent of the neuronal connections in their brains, which can be repaired when at least a week of rest is provided. The fact that male and female brains are “wired” differently could account for a higher incidence of and/or a longer healing period after brain injury in women.

Realistically, interplay of all of these factors could potentially influence the differences in concussions between the number of concussions of female athletes and their recovery.

Periodically when I’m seeing patients in our HeadFirst concussion clinics, parents will ask me about a different brain trauma-related studies that they’ve heard about. These questions range from studies about concussion-healing chocolate milk to eye tracking devices to the effectiveness of helmets and different sports bands preventing head injuries. Presently, NO concussion treatments have been approved by the United States Food and Drug Administration (FDA). Likewise, the FDA has yet to approve of any devices that prevent concussions in the first place. No helmets, no mouth guards, no sports band or other piece of technology in any way shape or form has been demonstrated to completely prevent concussions.

I typically advise parents to be extremely cautious with new research or technology, or with the promises of concussion treatment. Instead, parents should seek out a concussion specialist who has years of experience treating these injuries and utilizes multiple methods in their assessment, diagnosis, and treatment planning.

CTE’s connection to football has been in the news for five years now, with a debate centered around whether the number of concussions will affect long-term health and well-being of those playing the sport. Likewise, I’m constantly asked by patients and parents what the future effect of this or future concussions will be on their health. A recent study released by researchers at the Boston University School of Medicine (such as Dr. Robert Cantu, Dr. Ann McKee, Chris Nowinski and others) will probably give moms and dads across America a moment of pause before starting a collision sport like football or hockey.

An answer may lie in a concept developed by these researchers called the Cumulative Head Impact Index (CHII). They found individuals who had more hits to their heads—regardless of whether they had a concussion or not, were significantly (i.e., not even close…a large statistic margin) more likely to experience later-life cognitive problems, apathy and depression. The caution here is that the sample size was only 93 individuals and the exposure was only to football.

The next step is for medical providers and concussion specialists to help families begin to connect the dots throughout the developmental hurdles of a child’s life. For example, the health outcomes for two 7th grade beginning hockey players if they have a different history. One student may have fallen off a changing table as an infant and suffered a skull fracture, have been in a motor vehicle accident, and have fallen multiple times during winter sports, while the other 7th grader may not have suffered any head injuries or significant head trauma. Baseline neurocognitive testing like the ImPACT® test might look different on these two young students, and the outcome and recovery time of any current injuries sustained by each of them could be considerably different.

I’ve often said that kids can’t live in a bubble as much as parents are sometimes inclined to want to wrap their kids in bubble wrap. Young people—really, people of all ages—are going to be in car accidents, bike accidents, and slip and fall just going through life. Parents need to make their own unique, informed decision about how much additional risk of physical injury to which they want to expose their child, given his or her medical history and athletic abilities.

How many times have you seen parents running their kids from one sporting event to the next? Parents and kids feel the pressure to stay on the best team, with the best trainer, and the best coach to continue to progress in their sport.

At what age should a child or teen begin to specialize in a sport? Should kids go the route of gymnastics and figure skating and focus exclusively at an early age or should specialization be held off until high school or college when bodies and minds begin to fully form and develop?

Having been in the military, I had the benefit of having my children participate in school systems and sports programs up and down the Eastern seaboard. School systems and sports programs are not all the same. The culture within these communities created by principals, athletic directors, teachers, coaches, athletes and parents were a direct result of their collective focus and values.

As a psychologist, what I have found interesting is that the value system of sports and athletics tends to mirror one another. Within one community, children are not cut from a sports team – all children up to 9th grade may be able to try out and play on any team without getting cut. In the same community, children may not receive letter grades – or “competitive grades” – until the 8th grade.

Elsewhere, however, I’ve seen children cut from teams and competing for spots as early as 1st grade, when they also begin receiving competitive letter grades.

As with many things, the trick is in finding the right balance. Children in 1st grade cognitively can’t keep score and focus on the tasks of what they need to do on the field. What does a “D” in reading really mean to a first grader? A summary letter grade is an abstract concept that doesn’t teach very young children that they need to read more to improve their proficiency. The same applies to sports. An older child can understand the causes and consequences of a low letter grade, be it in academics or sports. But is waiting until 9th grade to be cut from a team too long to teach the lesson that life is competitive?

Another factor to consider are that traumatic brain injuries (concussions) will interrupt an athlete’s season and training. The type of community a child is living in and the focus of the coach, parents, athletic trainers, administrators, and other adults working, training and living with these young athletes can affect treatment outcomes in case of a concussion. Is your community one that is fostering hyper-competition that is focused on the top one percent or does it focus on age-appropriate health and well-being of all its children and how they all can benefit from athletic competition?

A recent Fox Sports article discusses the youth concussion laws that have passed in all 50 states and the District of Columbia, but it also highlights some key elements that were missed.

Over the past five years, each state has modeled their laws after the State of Washington law in 2009, also known as “The Zackery Lystedt Law” after a high school athlete who suffered a life-changing concussion (pictured below, pre-injury and today, with his father).

Unfortunately, only 21 states have implemented all four key components of Washington’s law, which is considered the gold standard by many professionals:

1. REMOVAL FROM PLAYThis is pretty basic. The science and medical reasons for asking a child or athlete to leave a game or practice when a concussion is suspected is in place so a second and potentially more dangerous concussion does not occur. As of today’s writing, neither Illinois nor Wyoming requires the removal of an athlete from play in such a scenario. Arizona and South Carolina allow an athlete to return to play the same day if cleared by a physician.

When a child is suspected of having a concussion, it is a good idea to at least wait 24 to 48 hours after the injury to ensure that symptoms do not develop. Here at HeadFirst, as many as 40% of our patients develop symptoms one to two days after their injury.

2. EDUCATIONFortunately, this is not as opposed as it was just three or four years ago. Coaches now realize the importance of receiving education about how to evaluate and treat a head injury. New York law requires not only coaches but also nurses, athletic trainers, and teachers to receive training on concussion and concussion management.

But New York is the exception and there are many states that don’t require education about concussion. Researchers and scientists also still need to do much in this area. Studies have not been completed on what coaches and athletic trainers know prior to training and what type of training is effective.

3. PARENTAL CONSENTThis is quite a basic component of the law which requires student athletes and parents to sign an informed consent stating they understand the dangers of the sport and that a concussion or traumatic brain injury is one of the risks involved in the sport.

4. MEDICAL CLEARANCEOnly 30 states have this element as part of their laws requiring clearance by a trained concussion healthcare provider prior to injured athletes’ return to play. Many laws and training programs also do not specify what training a concussion specialist needs or requires.

Even though these elements are a good first step, they’re still not enough to protect our children. A carefully designed return-to-learn plan is just as important in concussion recovery since academic demands can slow brain healing. Unfortunately, only two states—Nebraska and Virginia—have return-to-learn elements within their concussion guidelines. These procedures require a school to be notified if a student has sustained a concussion and then to give that student accommodations due to the injury.

Some states have even made unsuccessful attempts to add supplementary requirements to their concussion laws.

Oklahoma tried to add a section to their law that would mandate suspensions and punishments on coaches and athletic trainers who didn’t follow concussion guidelines.

Massachusetts attempted to add required neurocognitive baseline testing for all high school students.

And, Maryland tried to add a requirement of helmet sensors on high schoolers’ helmets before basic scientific research had been completed on the sensors or the meaning of a positive or negative sensor result.

A number research studies continue to suggest the negative effects of alcohol (and other recreational drug use) after brain injury.

Alcohol is a neurotoxin — meaning alcohol kills brain cells — exacerbating the effects of a concussion. There is no recommended safe amount of alcohol or recreational drug use after a concussion. Even moderate amounts of alcohol for people with a concussion have been associated with increased deficits in memory, attention and balance.

Additionally, heavy pre-injury alcohol consumption is associated with poorer health outcomes and substance abuse post-injury. Many concussion patients report they are more sensitive to the effects of alcohol after injury. Even a small amount of alcohol after a concussion can impair judgment and increase the risk of a fall (and subsequent head injury).

One of the most common questions that I get from parents is “How well will my child’s helmet protect against concussion?”

The elusive answer appears to have been provided at the 2014 American Academy of Neurology’s annual meeting. In a study co-authored by Frank Conidi, MD, DO, MS, director of the Florida Center for Headache and Sports Neurology, Assistant Clinical Professor of Neurology at Florida State University College of Medicine, the standard drop test was modified to measure linear and rotational responses in crash test dummies to repeated 12 mile-per-hour impacts.

They found that helmets do protect the player from massive injuries like skull fractures in the range of 70 to 80 percent but provide little to no protection against concussion in the range of 10 to 15 percent.

Why is that? While the helmet does its job in disbursing the impact of a hard hit across the helmet to greatly reduce the risk of a skull fracture at one specific site, a helmet cannot stop the brain from shaking inside the skull, thus providing little to no protection against a concussion.

In fact, the team of scientists found that football helmets, on average, reduce the risk of traumatic brain injury by only 20 percent compared to not wearing a helmet. Added to these statistics, Conidi says, “Alarmingly, those that offered the least protection are among the most popular on the field.”

One of the best tools we have available is neurocognitive baseline testing. With the beginning of the school year upon us, please remember to get your child baseline tested. Headfirst Concussion Care offers free ImPACT® baseline testing. Please call 1-855-748-4868 (SIT-IT-OUT) or visit us online to arrange your child’s appointment.